MEDICARE: PAIN MANAGEMENT SOLUTION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0014X	Interventional Pain Medicine Physician
2	208VP0000X	Pain Medicine Physician

General Provider Information

NPI Number	:	1871050781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN MANAGEMENT SOLUTION LLC

Provider Business Mailing Address
First Line	:	730 EXECUTIVE PARK DR STE A
Second Line	:
City	:	GREENWOOD
State	:	IN
Zip	:	46143-3213
Country	:	US
Telephone Number	:	317-346-7246
Fax Number	:	317-534-3763

Provider Business Practice Location Address
First Line	:	4010 W GOELLER BLVD STE C
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-8312
Country	:	US
Telephone Number	:	317-346-7246
Fax Number	:	317-534-3763

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	GREGORY SCOTT MASIMORE
Credential	:	MD
Telephone Number	:	317-346-7246

Provider Enumeration Date	:	02/27/2019
Last Update Date	:	02/27/2019

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Directions to “PAIN MANAGEMENT SOLUTION LLC ” Practice Location

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